Nurse prescriber Tanya Albin offers advice on elective filler dissolving treatment and supporting patients through the change
Elective filler dissolving has risen steeply in recent years, with an increasing number of public figures openly discussing reversing their previous procedures.1 This would directly correlate with the trends we are seeing in clinic with more natural looks being frequently requested. But what significance can the dissolving process have on our patients?
Hyaluronidase, which is an enzyme that breaks down hyaluronic acid, has been administered in medical applications for more than 60 years, originally being used to increase the absorption of drugs into tissue and reduce tissue damage in cases of extravasation of a drug.2
Since its first use in aesthetics in 2007, its utilisation has been on the rise, and not just for emergency reversals.3 This article will explore the impact of both overfilling and dissolving on patients’ wellbeing, alongside clinical guidance on effective dissolving and post-treatment care.
When dissolving should be encouraged
Patients may not have considered dissolving poor dermal filler treatments and may present as ‘filler blind’, however, as clinicians we have a duty of care to ensure we are offering our patients the best possible outcomes rather than continuing to refill at the patient’s request. You may have to say ‘no’ to your patient if you believe that another treatment could be clinically damaging.
I have found that having a thorough initial consultation of at least 45 minutes to establish desired outcomes and the risks associated with potential overfilling should help educate patients about their decision-making. For example, when it comes to lip augmentation, I strongly recommend opting for shape over volume to maintain definition of the vermillion border.
Over the years, I have learnt to become more direct about overfilling, as I believe it is my duty of care to avoid unnecessary treatment. Ultimately, we can encourage patients to make an informed choice, but some may wish to refuse elective dissolving. Ethically, at this point, refusal of further treatments should be verbalised and clearly documented.
The mental impact
Many patients, however, do not need to be encouraged to dissolve their existing filler. Patients are looking for more natural approaches to aesthetic procedures and are embarking on filler dissolving journeys in the hope of pursuing more natural alternatives.
They are actively seeking out dissolving of previously injected dermal fillers, especially after potentially becoming ‘overfilled’ and ‘pillowy’ as a result of package deals, misinformation and online trends.4 With this rise in elective hyaluronidase, it is important as practitioners that we are equipped not only with the tools and education to safely conduct the procedure, but also knowledge of how to consult our patients beforehand.
Many patients will have had their filler for several years and will be accustomed to their appearance, so may be distressed and self-conscious when it is reversed. It is imperative that they are well educated as to what the procedure entails and the effects this change in appearance can temporarily have on mental, physical and emotional wellbeing.
A contributing behavioural factor to this has been referred to as ‘perception drift’.5 In settings where the overfilled aesthetic becomes prevalent, the distorted appearance transforms into the norm, potentially becoming an aesthetic ideal. With each successive treatment, the patient’s memory of their natural appearance can be obscured.
As exposure to manipulated features increases, patients can end up with a distorted ideal, opting for treatments which take them further and further from their original features. In my clinic, alongside their consultation, patients must complete a body dysmorphic disorder (BDD) questionnaire upon arrival, which helps to highlight any potential issues relating to anxieties surrounding appearance.6
Medical images of your patient should be taken and clearly stored in your patient notes for reference, primarily as a means of medicolegal protection. Second, it documents the efficacy of a treatment, and images can be used as a reference for your patient who can forget how they looked prior.2,7
Pre-treatment considerations
It is imperative that patient safety considerations are discussed before and during elective dissolving. Local injections of hyaluronidase can cause side effects such as local pruritus, swelling and allergic reactions. The incidence of allergic reactions is reported to be 0.05% to 0.69%, and urticaria and angioedema have also been reported to occur at a low frequency.2
Allergy to hyaluronidase is reported as being from earlier bee/wasp venom sensitivity, or previous hyaluronidase treatment.8 In this instance, patients would be contraindicated to elective dissolving, and should be cautioned about any future dermal filler procedures.
Intradermal skin allergy testing (IDT) is prevalent in the practice of medical aesthetics, but is heavily debated in the literature in terms of the need and accuracy, so the decision to carry it out is dependent on the practitioner.9,10,14 Despite this, the Complications in Medical Aesthetics Collaborative (CMAC) does provide guidelines on how to carry out IDT, and the Aesthetics Complications Expert (ACE) Group World also recommends it.9,10
The test is often deployed as a method of ‘reassuring’ the practitioner that the patient will not develop anaphylaxis. Practitioners should be aware that most reactions to hyaluronidase are delayed type IV sensitivity reactions and may only present days after the test.9
It is my preference to perform IDT so that every possible step to highlight potential allergy has been made and is clearly documented. This is to reassure the patient and myself that I have tried to mitigate any risk. I carry out the test by injecting 0.02-0.05ml until a wheal (i.e. a bleb) is present, and marking around the bleb with a pen so I can visualise any possible reactions.
It is also recommended by CMAC to inject a small control amount of normal saline approximately 2cm away and observe the patient for 20 minutes before taking any further action.9 It is worth noting that whatever the testing policy in your clinic, in emergencies such as vascular occlusion, the risks of delaying treatment outweigh the benefit of conducting such a test.10,11
Appropriate complications training is imperative before any clinician undertakes a dissolving procedure. They should ensure their emergency kit holds the clinical protocol for allergy management and anaphylaxis guidelines to ensure that in case of allergy, the patient can be safely and appropriately managed. Emergency kits should include adrenaline 1:1000 (1mg/1ml), and follow the General Resuscitation Council Guidelines.12
Carrying out the dissolving
Following appropriate consultation, medical history, consent and possible testing, the patient can be prepared for elective dissolve. Most commercially available hyaluronidase brands consist of lyophilised powder, which can be diluted with both normal saline and bacteriostatic saline. The latter is preferred as this lends to a more comfortable injection.9
The most common hyaluronidase brand, Hyalase, comes as a dry powdered vial containing 1:500 units per ml. There are varying recommendations for how to reconstitute, and with which solution. A range of 1-10mls has been evidenced in clinical practice.8,9 In clinic, I find reconstitution in 2ml bacteriostatic saline has a desirable clinical outcome for elective dissolving.
It is important to consider that the higher the molecular weight, cross-linking and volume of hyaluronic acid in the product you are dissolving, the higher the required dose of hyaluronidase and the potential number of sessions.13 Doses should be titrated according to clinical effect.14
If the patient is unsure of what product was originally injected and at what volume, multiple appointments may be needed to complete the dissolving depending on response. A 2023 study into 18 varying dermal filler brands showed that all were dissolved with hyaluronidase within 32 minutes, thus evidence suggests most HA fillers will respond well to hyaluronidase.15
Prior to injection, the area should be inspected, palpated and clearly marked out. It should then be cleansed using a suitable skin solution, for example a hypochlorous solution like Clinisept+. Methods of delivery can vary, with larger treatment areas requiring delivery via cannula to enable larger disbursement and minimise needle entry points.
For example, using a cannula to the mid-face and jawline may be preferable over the needling technique as it can be more comfortable in these large areas.10 For filler nodules or localised migration such as in the lip, it may be preferable to use more precise delivery via needle.10
In the event of a nodule, there may be resistance when injecting; however, it is important to try to penetrate the nodule to remove the filler successfully.8 All treatments with hyaluronidase, regardless of the method of delivery, should be massaged following placement to aid the mechanical breakdown of the filler and ensure the hyaluronidase is dispersed.8
A growing technique that should be considered for both administration of dermal fillers and dissolving is the use of ultrasound. Ultrasound guided dissolving is particularly beneficial as you can target exactly where the dermal filler is in situ, ensuring more precise injections. However, safe performance of this method requires sufficient understanding of facial anatomy and how to interpret the ultrasound images.
The use of topical applied hyaluronidase – Topilase – has gained popularity and can be beneficial for localised improvement of overfilling and Tyndall Effect in the tear trough region.16 This is a far less invasive choice suitable for practitioners to prescribe for minor corrections rather than complete dissolving.16
Patients can use the treatment at home a maximum of three times at three weekly intervals, depending on the amount of product which needs to be dissolved.16 It should be massaged vigorously into the skin for three to five minutes.16 Injectable hyaluronidase aftercare guidance should consist of immediate observation; asking the patient to wait in clinic for 30 minutes following treatment can be beneficial in terms of monitoring signs of reaction.
Common reactions with hyaluronidase can be localised swelling, angioedema, bruising and less often anaphylaxis.17,18 Home care advice consists of analgesia if needed, keeping the area clean and using a cool compress for swelling and minor discomfort.15
Topical hyaluronidase does not require such stringent aftercare.16 Patients should be informed that whilst injectable hyaluronidase effects are immediate with a half-life of two minutes, peak effects can be seen around 24-48 hours, and they can continue to develop for up to two weeks after treatment.4 A review should be scheduled two weeks following the first treatment to ensure an appropriate response and to allow for further treatment if needed, or to begin the next stage of their treatment plan.15
Restorative treatments
In a recent study looking at post-dissolving skin, patients reported a negative effect on appearance after hyaluronidase treatment.18 This phenomenon is referred to in this study as ‘post-hyaluronidase syndrome’, which is defined as any of the following facial changes: hollowing of the facial tissues, loss of skin elasticity or discolouration of the skin.18,19
Indeed, following removal of fillers, the skin may show an appearance of looseness and loss of elasticity.19 A confounding factor is that natural age-related changes may have occurred while the filler has been in situ.19 Therefore, the importance of good skin health should be discussed, and I recommend that a medical-grade skincare regime be commenced before dissolving to prep the skin and ensure the best possible results.
Nevertheless, patients should be made aware of the possible need for careful refilling or other modalities that can help improve tissue quality, depending on the outcome of treatment. I find that options such as radiofrequency (RF) microneedling, polynucleotides or exosomes can be beneficial to restore skin health to its optimal state following the overfilling and dissolving process.
These procedures can be commenced as early as two weeks after dissolving. I favour an approach combining polynucleotides and RF microneedling. Polynucleotides work by stimulating fibroblasts, which encourages cell turnover, improves elasticity, boosts collagen production and hydrates skin with wound-healing polymers.16
They also calm inflammation and rebalance melanocyte activity to create an even skin tone.16 I find this works well to prep the skin before potential refilling. My product of choice is Plinest from Mastelli by DermaFocus. After the skin is primed with this, RF microneedling can be applied to increase collagen and elasticity.
This works by providing a controlled, localised thermal effect on the dermis, triggering the body’s healing processes and inducing skin tightening.17 I prefer Morpheus8 from InMode, but of course, there are numerous other treatment combinations you could suggest to patients to rejuvenate their skin post-dissolving.
It is essential that a plan is in place for further or alternative treatments before the dissolving is conducted, as this can help patients feel more in control of the process and meet their expectations clearly. Patients should feel heard and supported following the dissolving process.
Dissolving with caution
Practitioners need to be well equipped with managing patient expectations when offering elective dermal filler dissolving as demand for it continues to grow. We must offer clear education and support for our patients, not only from a medical procedural point of view, but also considering the impact dissolving can have on patients.
Tanya Albin has worked in the aesthetic field for 14 years, while also continuing to work in the NHS, background in acute care within A&E, theatres, ITU and prison nursing. She owns her own CQC-registered clinic in Canterbury, Kent.
References
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Murray G, Convery C, Walker L, Davies E. Guideline for the Safe Use of Hyaluronidase in Aesthetic Medicine, Including Modified High-dose Protocol. J Clin Aesthet Dermatol. 2021 Aug;14(8) Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8370451/ [Accessed 2024 May 13].
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ACE Group World (2017) <https://www.bacn.org.uk/content/large/documents/members_documents/complications_guidance/acegrouphyaluronidasev2.4.pdf>
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Resuscitation Council UK (2024) Guidance: Anaphylaxis. Available at: https://www.resus.org.uk/sites/default/files/2021-05/Emergency%20Treatment%20of%20Anaphylaxis%20May%202021_0.pdf. [Accessed: 1st July 2024]
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King M, Convery C, Davies E. The use of hyaluronidase in clinical practice. Aesthetic Complications Expert Group. 2019. Available from: https://www.bacn.org.uk/content/large/documents/members_documents/complications_guidance/acegrouphyaluronidasev2.4.pdf [Accessed 2024 Jun 29].
Reddy S, Mihori M, Rostami S. In Vitro Analysis of Dissolution of 18 HA-based Dermal Fillers with Tailored Hyaluronidase Dosing to Achieve Urgent Reversal of Vascular Complications. Am J Cosmet Surg. 2023;0(0). Available from: https://doi.org/10.1177/07488068231210181 [Accessed 2024 Jun 29].
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